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MEMBER RESOURCES > APPEALS OR EXCEPTIONS

Appoint a representative, file a grievance or appeal,
request a coverage determination, and more.

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Organization Determination

 

To request an organization determination (also called a prior authorization), you can call, mail, or fax your request:

Phone:

Fax: 1-833-610-2399

Mail:

Align Senior Care
PO Box 40
Glen Burnie, MD 21060

What happens next?

We will review your request and send you a decision:

  • Standard medical requests: within 7 days
  • Standard Part B drug requests: within 72 hours
  • Expedited medical requests: within 72 hours
  • Expedited Part B drug requests: within 24 hours
What is an organization determination?

An organization determination is a decision (approval, partial approval, or denial) about your care or coverage.

This includes decisions about:

  • Whether a service or item is covered
  • How much you need to pay
  • Limits on services or treatment

In simple terms, this is when Align Senior Care decides whether to approve, provide, or pay for your care.

You can also ask for a fast (expedited) decision if waiting could seriously harm your health or ability to recover.

Who can request an organization determination?

A request may be made by:

  • You (the member)
  • Your authorized representative
  • Your doctor or other provider

Fast (expedited) requests may be made by:

  • You
  • Your representative
  • Any physician, even if they are not in our network
Do I need to name a representative?

You can choose someone to act for you, called an appointed representative.

You and your representative must complete and sign an Appointment of Representative (AOR) form

This form is not required if your doctor is making the request for you.

Send the completed form to:

Fax: 1-833-610-2399

Mail:
Align Senior Care
PO Box 40
Glen Burnie, MD 21060

When can an organization determination be requested?

You can request an organization determination when you need a decision about:

  • Payment for certain urgent or out-of-area services.
  • Services you already received that you believe should be covered.
  • A denial of care, services, or payment.
  • Changes to ongoing treatment (such as reduced or stopped care).
  • Delays in getting approval, care, or payment that could affect your health.
What are important things to know?

Emergency services do not require prior authorization.

If your request is approved, the approval is valid for the time listed in your notice. If you do not agree with the decision, you have the right to file an appeal.

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